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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603371
Report Date: 08/25/2023
Date Signed: 08/25/2023 11:56:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2020 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20200527130759
FACILITY NAME:MERRILL GARDENS AT OCEANSIDEFACILITY NUMBER:
374603371
ADMINISTRATOR:PEREZ, MARIANOFACILITY TYPE:
740
ADDRESS:3500 LAKE BLVDTELEPHONE:
(760) 414-9411
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:0CENSUS: 0DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Closed Facility - report sent via USPS certified mailTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Resident sustained fracture while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno delivered findings via United States Mail with proof of delivery as facility staff were not available due to facility closure. with an effective date of, September 24, 2021.

The Department investigated the above-listed complaint allegation. The investigation consisted of an inspection of the facility, observations, multiple interviews with staff, and outside sources, and a detailed review of resident records, including medical records, and service care plans.

On May 27, 2020, Community Care Licensing (CCL) received a complaint alleging that a resident (R1) sustained a fracture while in care, [an LIC 811 Confidential Names List was provided to staff to identify the resident].
(continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 08-AS-20200527130759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MERRILL GARDENS AT OCEANSIDE
FACILITY NUMBER: 374603371
VISIT DATE: 08/25/2023
NARRATIVE
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(continue from LIC9099)

It was specifically alleged that on April 7, 2020, R1 had an unwitnessed fall and sustained a fractured back. In addition, R1 was observed with discoloration to the left side of their neck and a cut on their left temple. During multiple interviews, staff indicated the source of the additional injuries was unknown. A detailed review of R1’s service care plan dated March 26, 2020, indicated that R1 was at high risk for falls and did not have a history of wandering. However, staff interviews disclosed that two weeks prior to R1’s unwitnessed fall, R1 had been observed wandering the halls unsupervised which was documented in the progress notes. A review of R1’s care plan disclosed that although R1 had been assessed as a high risk for falls and had a history of wandering staff failed to incorporate safety measures to protect R1’s health and safety. After the unwitnessed fall incident, on April 13, 2020, a bed rail was ordered for R1. In addition, safety checks every 60 minutes were also instituted. Based on the review of R1’s and facility records and information obtained from multiple interviews with staff and outside sources there was sufficient corroboration and evidence to show the facility failed to put safety measures in place to mitigate R1’s fall.

The Department has investigated the above-mentioned allegation and has found that there was sufficient evidence to corroborate the allegation. Therefore, this allegation is deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A Deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. The facility implemented additional fall safety measures and increased monitoring. Facility closed effective 9/24/21.

A copy of this report, LIC 9099D, Confidential Name List (LIC 811), along Licensee/Appeal Rights (LIC 9058 03/22) were mailed to the last known address on file.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20200527130759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MERRILL GARDENS AT OCEANSIDE
FACILITY NUMBER: 374603371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
87464(f)(1)
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87464(f)(1) BASIC SERVICES
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). "Care and supervision" means the facility assumes responsibility for or provides... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by:
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Facility implemented additional fall safety measures and increased monitoring. Facility closed effective 9/24/21.
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Based on interviews and record review, the licensee failed to provide adequate care and supervision to R1 which resulted in serious bodily injuries. This posed an immediate health and safety risk to R1, one of 129 residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2020 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20200527130759

FACILITY NAME:MERRILL GARDENS AT OCEANSIDEFACILITY NUMBER:
374603371
ADMINISTRATOR:PEREZ, MARIANOFACILITY TYPE:
740
ADDRESS:3500 LAKE BLVDTELEPHONE:
(760) 414-9411
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:0CENSUS: 0DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Closed Facility - report sent via USPS certified mailTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff neglect led to resident sustaining multiple pressure injuries
Staff neglected resident resulting in weight loss
Resident sustained an ankle sprain
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno delivered findings via United States Mail with proof of delivery as facility staff were not available due to facility closure with an effective date of, September 24, 2021.

The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, observations, multiple interviews with staff, and outside sources, and a detailed review of resident records, including medical records, and service care plans.

On May 27, 2020, Community Care Licensing (CCL) received a complaint alleging that facility staff neglect resulted in a resident (R1) sustaining multiple pressure injuries. [an LIC 811 Confidential Names List was provided to staff to identify the resident].
(continue on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20200527130759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MERRILL GARDENS AT OCEANSIDE
FACILITY NUMBER: 374603371
VISIT DATE: 08/25/2023
NARRATIVE
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(continue from LIC9099A)

A detailed review of R1’s records indicated that on May 2, 2020, R1 had a documented skin/tissue integrity condition that was healing on their left heel and left gluteal cleft (sacrum). R1 was under medical care by an outside medical provider. A review of R1’s care plan indicated that specific instructions were given to facility staff on how to address the wounds. Staff patted the wounds and applied Calmoseptine ointment (multipurpose moisture barrier that protects and helps heal skin irritations) routinely as prescribed in the service care plan. According to R1’s medical records, the pressure injuries were never staged above level 1 or 2 and were being closely monitored by outside medical providers. In addition, according to the medical provider's notes, R1’s pressure injuries were not considered to be a prohibited condition for R1 not to remain at the facility. Based on the detailed review of medical records, R1’s service care plans, and multiple interviews with staff and outside sources there was insufficient evidence to indicate that staff neglect resulted in R1’s sustaining pressure injuries.

It was also alleged that staff neglected R1 resulting in weight loss. A review of R1’s documented medical condition and service care plans as well as multiple interviews with staff and outside sources indicated that R1 had a change in condition with eating habits. R1 was pocketing their food and was having difficulty chewing and swallowing food. A review of R1’s progress notes indicated that R1’s diet changed from mechanical to puree and the percentage of food intake decreased more and more as R1’s health condition declined. Multiple interviews with staff and outside sources consistently confirmed that R1 was encouraged to eat and drink more liquids as specified in the service plan. The investigation disclosed no evidence to support that facility staff failed to provide adequate nutrition to R1.

It was also alleged that R1 sustained an ankle sprain while in care. On April 30, 2020, R1 was transported to the hospital for an evaluation of their ankle, which was diagnosed as soft tissue swelling. It is unknown if this injury happened on April 7, 2020, when R1 had an unwitnessed fall or if occurred while R1 remained at the hospital. The investigation did not disclose enough evidence to indicate that facility staff was neglectful as staff obtained immediate medical attention when R1 experienced a change in medical condition.

(Continue on LIC9099C)
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20200527130759
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MERRILL GARDENS AT OCEANSIDE
FACILITY NUMBER: 374603371
VISIT DATE: 08/25/2023
NARRATIVE
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Continued from LIC9099C


The Department has investigated the allegations and has found that there was insufficient evidence to corroborate the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are deemed to be unsubstantiated.

A copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were mailed to the last known address on file.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6